Thoracic Surgery

Question 2

A patient who underwent a thoracotomy six months ago reports shooting pain on
the chest wall occurring without any trigger. This is known as:

Post thoracotomy pain syndrome

Answer 2

IASP Post-thoracotomy pain syndrome:
“Pain that recurs or persists along a thoracotomy incision at least two months following the surgical procedure” in general it is burning or stabbing pain with dysesthesia thus shares many features of neuropathic pain.

Dysesthesia: unpleasant abnormal sensation spontaneous or evoked

Question 3

A 69-year-old patient is dyspnoeic and complains of right shoulder tip pain while in the post-anaesthesia care unit after a laparoscopic-assisted anterior resection. A focused thoracic ultrasound is performed and an image of the right lung is shown below. This represents:

a) Pneumothorax
b) Pulmonary Oedema
c) Normal Lung
d) Consolidated Lung

Answer 3

REPEAT

c) Normal Lung

Normal lung = A lines (pleura) + batwing appearance + sliding

Question 4

The following is a chest X-ray from a patient with dyspnoea after thoracic surgery.
The diagnosis is:

A. Dextracardia
B. Cardiac hernation
C. LLL collapse
D. Tension Pneumohorax

Answer 4

REPEAT

Question 5

A patient has blunt chest trauma. A thoracotomy is indicated if the immediate blood drainage after closed thoracostomy is greater than:

a) 500mL
b) 750mL
c) 1L
d) 1.2L
e) 1.5L

Answer 5

REPEAT

1,500 mL immediately

OR

200 mL/hr in the first 2-4 hours

Question 6

NP B lines (comet tails) in lung ultrasound are NOT observed in:

a) ARDS
b) Interstitial
c) Normal lung
d) Pneumothorax

Answer 6

D) pneumothorax

From BJA 2016 lung US article

The features of a pneumothorax are abolished sliding, absence of B lines, absence of the lung pulse, and presence of the lung point

Question 7

You have been asked to provide general anaesthesia for a complex thoracic endovascular aortic aneurysm repair. After the placement of a lumbar drain the recommended safe time before the administration of intravenous heparin is

a) 1 hour
b) 4 hours
c) 6 hours
d) 12 hours

Answer 7

AT - 1 hour

1.2.3 Time of lumbar drain placement to systemic intravenous heparinization should be greater than 60 minutes

Perioperative Management of Adult Patients with External Ventricular and Lumbar Drains Guidelines from the Society for Neuroscience in Anesthesiology and Critical Care

ASRA: 1 hour

Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case are warranted.

Currently, insufficient data and experience are available to determine if the risk of neuraxial haematoma is increased when combining neuraxial techniques with the full anticoagulation of cardiac surgery. We suggest postoperative monitoring of neurologic function and selection of neuraxial solutions that minimise sensory and motor block to facilitate detection of new/progressive neurodeficits.

NYSORA:
Administration of intravenous heparin intraoperatively should be delayed for at least 1 hour after epidural placement; a delay before administration of subcutaneous heparin is not required. In cases of full heparinization for CPB, additional precautions include delaying surgery for 24 hours in the event of a traumatic tap, tightly controlling the heparin effect and reversal, and removing catheters when normal coagulation is restored.

Question 8

NP A 65-year-old presents with an acute dissection of their thoracic aorta. Their blood pressure is 150/90 mmHg. The best medication to reduce the blood pressure is:

a) Esmolol
b) SNP
c) GTN
d) Hydralazine

Answer 8

A) esmolol

They get anti impulse therapy which usually starts off with beta blockade before alpha blockade.

Up to date: Patients often present with severe hypertension and are initially stabilized with fast-acting, intravenous beta blockers (eg, esmolol or labetalol) or calcium channel blockers. Anti-impulse therapy lowers blood pressure

Question 9

Kate For driving pressure guided ventilation, driving pressure is the:

a) Pplat-peep
b) Peak pressure-peep
c) Other formulas

Answer 9

Pplat-PEEP

driving pressure is defined as distending pressure above the applied Peep Required to generate Vt
- key variable for optimisation when performing mechanical ventilation in ARDS
- also Vt/CRS (Ratio of Tidal volume to static resp system compliance)

Question 10

21.1 The lung ultrasound finding most consistent with atelectasis is three or more

A. B lines
B. A lines
C. Comet tails
D. Z lines
E. Lung Pulse

Answer 10

comet tails or B-lines

useful resource: https://academic.oup.com/bjaed/article/16/2/39/2897763

Comet Tail artefact:
- a short path reverberation artefact that weakens with each reverberation, resulting in a vertical echogenic artefact that rapidly fades as it continues in to the ultrasound image.
https://litfl.com/comet-tail-artefact/

Short path reverberation artefact
- The ultrasound appearance of this artefact is a thin vertical bright or echogenic line that passes from the point of origin, to the deepest part of the ultrasound image.

• When appearing deep to the pleural line these are known as B-lines.
• Elsewhere in the body the identical artefact is known as ring down artefact.
• Where these artefacts fade quickly they are called comet tail artefacts

https://litfl.com/short-path-reverberation-artefact/

Radiopedia “B-line distribution corresponds with sub-pleural thickened interlobular septa” - more consistent with homogenous atelectasis

Question 11

20.1 In a Blalock–Taussig shunt, blood passes to the pulmonary artery via the

a. Aorta
b. Subclavian artery
c. IVC
d. SVC
e. Left atrium

Answer 11

B

Question 12

21.2 You have been asked to provide general anaesthesia for a complex thoracic endovascular aortic aneurysm repair. After the placement of a lumbar drain the recommended safe time before the administration of intravenous heparin is

a) 1 hour
b) 4 hours
c) 6 hours
d) 12 hours

Answer 12

1 hour

ASRA: 1 hour

Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case are warranted.

Currently, insufficient data and experience are available to determine if the risk of neuraxial haematoma is increased when combining neuraxial techniques with the full anticoagulation of cardiac surgery. We suggest postoperative monitoring of neurologic function and selection of neuraxial solutions that minimise sensory and motor block to facilitate detection of new/progressive neurodeficits.

NYSORA:
Administration of intravenous heparin intraoperatively should be delayed for at least 1 hour after epidural placement; a delay before administration of subcutaneous heparin is not required. In cases of full heparinization for CPB, additional precautions include delaying surgery for 24 hours in the event of a traumatic tap, tightly controlling the heparin effect and reversal, and removing catheters when normal coagulation is restored.

Question 13

21.1 The part of the lung that is typically divided into superior, medial, anterior, lateral and posterior bronchial segments is the

A. Right Upper lobe
B. Right Lower lobe
C. Left Upper lobe
D. Right Middle lobe
E. Lingula

Answer 13

RLL
1.Superior (apical bronchus 6)
-> most common site for foreign body or secretions to collect if patient laying flat in bed

Question 14

20.1 You want to position a internal jugular CVL with a CXR at the caval-atrial junction. Where is this?

a) 2 vertebral bodies superior to carina
b) 1 vertebral body superior to carina
c) At the carina
d) 1 vertebral body inferior to carina
e) 2 vertebral bodies inferior to carina

Answer 14

e) 2 vertebral bodies inferior to carina

Question 15

23.1 The following is a chest X-ray from a patient complaining of dyspnoea after thoracic surgery. The diagnosis is

(not the image from the exam)

A. Dextracardia
B. Cardiac hernation
C. LLL collapse
D. Tension Pneumohorax

Answer 15

B. Cardiac hernation

https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.109.896829

Question 16

21.2, 22.2 A patient has blunt chest trauma. A thoracotomy is indicated if the immediate blood drainage after closed thoracostomy is greater than

a) 500mL
b) 750mL
c) 1L
d) 1.2L
e) 1.5L

Answer 16

1,500 mL immediately

OR

200 mL/hr in the first 2-4 hours

Question 17

21.2 The number of segments in the lower lobe of the left lung is
a) 3
b) 4
c) 5
d) 10
e) 12

Answer 17

b) 4

Right lung:
RUL: APA
RML: LM
RLL: SMALP

Left lung:
LUL: ASIA (S&I form the lingular lobe)
LLL: ALPS

Subsegments (total of 42)
Left: 10 + 10
Right: 6 + 4 + 12

Question 18

22.1 This posteroanterior chest X-ray shows enlargement of the
(everyone seems to be unsure of answer, no image supplied)

a. Aorta
b. RA
c. RV
d. LA
e. LV

Question 19

22.2 A thoracic regional technique that will NOT provide analgesia for sternal fractures is a
a. PECS I
b. PECS II
c. Parasternal intercostal nerve block?
d. Transfascial muscle block (can’t remember wording)
e. transverse thoracic plane block

Answer 19

b. PECS I

(PECS II Covers SA and will extend to the sternum)

Question 20

20.1 What is the abnormality in this CXR?

a. Pneumonectomy
b. Pleural effusion
c. Pneumonia
d. Unilateral pulmonary oedema

Answer 20

c. Pneumonia

Complete white-out of left lung with air bronchogram sign consistent with total consolidation. Patchy areas of ground glass opacities in right lung. There is silhouetting of the left heart border and left hemi-diaphragm. There is no rib crowding to suggest atelectasis.

Complete white-out of the hemithorax with air bronchograms and trachea in a central position is consistent with consolidation secondary to pneumonia. The patient is on linezolid, micafungin, and piperacillin-tazobactam pending culture and susceptibility studies.

Differential diagnosis of hemithorax white-out with a midline trachea include:
- consolidation
- pulmonary edema/ARDS
- pleural mass
- chest wall mass

Question 21

22.1 An asymptomatic 65-year-old male with squamous cell carcinoma of the left lung has been referred for assessment of suitability for lung resection. There is no evidence of spread on computerised tomography scanning. PaCO2, electrocardiogram, full blood count and electrolytes are normal. His SpO2 on room air is 95%. His forced expiratory volume in one second is 2.3 litres (predicted 3.3 litres) and forced vital capacity is 3.4 litres (predicted 4.4 litres). The most appropriate course of action is to

a. Proceed with lobectomy or pneumonectomy
b. Proceed with lobectomy only
c. DLCO testing
d. Lung V/Q scan
e. CPET

Answer 21

a. Proceed with lobectomy or pneumonectomy

FEV1 surgical suitability:
- >80% or >2l pneumonectomy
○ no further testing required
- >80% or >1.5l lobectomy
○ no further testing required
- <80% or <2l for pneumonectomy
○ -> calculate ppoFEV1
- <80% or <1.5l for lobectomy
○ -> perform DLCO and express as % of predicted DLCO
○ Saturations on air
- ppoFEV1 < 40% and DLCO <40% = High Risk
- ppoFEV1 >40% and DLCO >40% and SaO2 >90% = Average risk (no further testing)

Question 22

20.2 This lung ultrasound shows

a) Normal lungs
b) Pulmonary odema
c) Pneumothorax
d) Pleural effusion
e) Pneumonia

Answer 22

b) Pulmonary oedema

B-lines

> Vertical echogenic short path reverberation artefacts originating at the pleural line and extending to the deepest part of the ultrasound image.
They interrupt any horizontal A-lines.
Occasional B-lines are considered normal.
More than 3 B-lines in any single view is considered pathological.
Where there are numerous B-lines in close proximity they become confluent.
B-lines move with lung movement.
They are caused by ultrasound energy reverberating in a fluid filled focus that is surrounded by air. These foci may be interstitial or alveolar.
Cardiogenic and noncardiogenic oedema may have very similar appearances.
Interstitial thickening due to fibrosis or lymphangitis can also create the sonographic appearance of diffuse B-lines.

Question 23

22.1 A patient with a haemopneumothorax has a chest drain in situ, which is attached to a three-bottle underwater seal drain apparatus. The system is attached to wall suction at -80 cmH20. This will cause

a) Failure of underwater seal
b) Water in suction chamber will enter drainage chamber
c) Reexpansion of haemopneumothorax
d) Oscillation in tube will diminish
e) Inability for stuff to drain into first bottle

Answer 23

Oscillations in the tube will be diminished

Question 24

20.2 A patient has a peripherally inserted central catheter (PICC) inserted. The follow-up chest X-ray shows the tip positioned in the (Chest X-Ray shown)

a) Azygos vein
b) Coronary sinus
c) SVC
d) R atrium
e) L atrium

Answer 24

a) Azygos vein

Correct positioning in image

Question 25

A 63-year-old man has undergone a right pneumonectomy for malignancy. Twelve hours postoperatively he suddenly develops profound hypotension and shock. Clinical examination reveals a raised central venous pressure. The most useful IMMEDIATE action would be to a. Turn left lateral b. Re-insert chest drain on operative site c. Tamponade

Answer 25

a) turn left lateral UTD: Cardiac herniation is usually seen within three days of surgery, presenting as sudden onset of hypotension and shock, cyanosis, chest pain, and superior vena cava syndrome. The acute event is usually preceded immediately by coughing, moving the patient, vomiting, or extubation. Treatment involves emergent surgery to reposition the heart and close the pericardial defect to prevent recurrence. ?bleeding Rapid filling of the PPS with blood can occur within 24 hours of surgery. This complication is more common after pleuropneumonectomy or pneumonectomy for suppurative lung disease. The clinical presentation may be with hypotension and shock due to the loss of intravascular blood volume. The mainstay of treatment is surgical reexploration and control of bleeding sources.

Question 26

21.1 The function of the bottle labelled 'D' in the diagram below is to protect against the consequences of (diagram of chest drain bottles) a. Suction failure b. Excess positive pressure c. Drain kinking d. Excess negative pressure

Answer 26

bottle A = fluid trap or collection bottle, can be independently emptied and allows accurate record of drainage amount - first tube connecting drain to drainage bottles must be wide to decreased resistance - volume capacity of this tube should exceed ½ of patient’s maximum inspiratory volume (otherwise H2O may enter chest) bottle B = underwater seal drain, maintained at a predetermined level whilst still allowing for drainage of pleural fluid (if bubbling continuously -> bronchopleural fistula) - volume of H2O in bottle B should exceed ½ patient’s maximum inspiratory volume to prevent indrawing of air during inspiration bottle C = manometer or pressure-regulating bottle allows suction to be attached and should bubble continuously - The maximum negative pressure (in cm H2O) generated by suction equals to the distance (in cm) the vent tube is below the water line (this can be adjusted) -The negative pressure generated by the vent tube is independent of the amount of pleural drainage that is collected in the trap bottle - If suction is turned off then tubing must be unplugged -> so air can escape into atmosphere

Question 27

23.1 A 69-year-old man is dyspnoeic and complains of right shoulder tip pain whilst in the postanaesthesia care unit after a laparoscopic-assisted anterior resection. A focused thoracic ultrasound is performed and an image of the right lung is shown below. This represents a) Pneumothorax b) Pulmonary Oedema c) Normal Lung d) Consolidated Lung

Answer 27

Normal Lung

Question 28

23. A 45 Year old man has poor oxygenation in the post anaesthesia care unit after a low anterior resection. His chest xray is below. The most likely diagnosis is a. LLL collapse b. Pneumothorax c. L pleural effusion d. R bronchopneumonia

Answer 28

The lungs are hyperinflated with relatively flat diaphragms - a sign of pulmonary emphysema. There is a dense triangular opacity overlying the cardiac shadow with increased lucency of the left upper zone relative to the right upper zone. This is the "sail sign" of left lower lobe collapse with subsequent left upper lobe hyper-expansion.

Question 29

A patient has undergone a laparotomy with a central line inserted intra-operatively. In the PACU, the patient is dyspnoeic and a lung ultrasound is performed. The ultrasound, shown below, is consistent with A. Pneumonia B. Effusion C. Normal lung D. Pneumothorax E. Pleural odema

Answer 29

C. Normal lung - shows sandy shore sign of normal lung sliding Alternative: Absent sliding & PTx: Stratosphere sign

Question 30

22.2 You are asked to review a 65-year-old man in the emergency department who has presented with hypoxia and confusion. The chest x-ray shows a left-sided a. Pneumothorax b. pneumonia c. one sided pulmonary oedema d. pleural effusion e. haemothorax

Answer 30

b. pneumonia Air bronchogram

Question 31

The part of the lung that is typically divided into medial and lateral segments is the a. Left upper lobe b. Lingula c. Right upper lobe d. Right middle lobe e. Right lower lobe

Answer 31

d. Right middle lobe

Question 32

21.1 The following is an image from a focussed cardiac ultrasound in a patient with dyspnoea presenting for thoracic surgery. The diagnosis is a) Pericardial effusion b) Tamponade c) Pleural effusion d) Loculated lung abscess

Answer 32

c) Pleural effusion Source: BJA Ultrasound in critical care Thoracic US revealing a large pleural effusion (E) that has displaced the lung. The diaphragm (D) and liver (L) are visualized. The depth from the skin to the fluid has been measured. Insertion of the needle at this site is not advised; given the proximity to the liver, a more superior approach should be marked.

Question 33

20.2 This lung ultrasound shows a) Normal lungs b) Pulmonary odema c) Pneumothorax d) Pleural effusion e) Pneumonia

Answer 33

a) Normal lungs Probe selection Linear probe (8–12 MHz) These high-frequency probes give good resolution of superficial structures. As the anterior pleura is relatively superficial, excellent images of the pleura and lung sliding can be obtained. The poor penetration of high-frequency US and the narrow sector width mean deeper structures are poorly imaged. Curvilinear probe (3–5 MHz) This is the best all-round probe for LU. Lung sliding can be easily visualized as can IS. Effusions, consolidated lung, and the diaphragm are also well imaged because of the good penetration and large sector width. The large footprint of the probe means some angulation is needed to avoid the ribs when scanning postero-laterally. Phased array (3–4.5 MHz) These probes have a useful footprint for getting in between the ribs. They can be used to demonstrate all the signs of LU but the clarity of the images is not as good. General points The clearest images are obtained by having the image as shallow as possible with the focus point at the level of interest. The frequency can be adjusted to enhance the image, depending on the depth. Increasing the frequency on a curvilinear probe will improve the appearance of lung sliding whilst worsening the appearance of a consolidated lung base.

Question 34

20.2 This lung ultrasound shows a) Normal lungs b) Pulmonary odema c) Pneumothorax d) Pleural effusion e) Pneumonia

Answer 34

e) Pneumonia Signs of Pneumonia on lung ultrasound: > Early Pneumonia - B-lines and areas of sub pleural consolidation - Fluid filled alveoli surrounded by air-filled lungs cause a short path reverberation and B-lines can be seen - localised patches of numerous B-lines indicate sub-pleural consolidation > Hepatization: solid appearing consolidated lung - inflammatoy and purulent fluid filled alveoli makes the lung appear solid, with homogenous relatively fine echotexture similar to liver - Atelectasis can also cause solid non-aerated lung and it can be difficult to distinguish the two conditions > Shred sign: irregular consolidation/ air interface - consolidated areas adjacent to aerated areas where the consolidated areas will be linear and well defined > Air bronchograms and dynamic air bronchograms - Air within consolidated area may remain in small aerated patches of lung or more commonly air remains within small bronchi, small air bubbles all lined up within a bronchus are known as sonographic air bronchograms - when air bubbles are seen to bubble in and out with each breath the term "dynamic air bronchogram" is used > Colour doppler interrogation: flow remains - pulmonary arterial and venous vasculature are well demonstrated in areas of consolidation Associated pleural effusion or empyema - small hyperechoic parapneumonic effusion are frequently demonstrated - echogenic debris within the effusion suggest empyema

Question 35

22.2 This lung ultrasound image is consistent with a. pulmonary oedema b. pneumonia c. pneumothorax d. pleural effusion e. Normal lung

Answer 35

c. pneumothorax

Question 36

A patient who underwent a thoracotomy 6 months ago reports ongoing pain caused by light brushing of clothes against the skin on the chest wall. This is known as a) Hyperalgesia b) Allodynia c) Hyperaesthesia d) dysasthesia

Answer 36

Mechanical allodynia Allodynia IASP definition: pain due to a stimulus that does not normally provoke pain “The term allodynia was originally introduced to separate from hyperalgesia and hyperesthesia, the conditions seen in patients with lesions of the nervous system where touch, light pressure, or moderate cold or warmth evoke pain when applied to apparently normal skin.” References IASP https://www.iasp-pain.org/resources/terminology/?ItemNumber=1698 And APMSE 5th Ed pg64. Dysaesthesia: spontaneous and unpleasant sensation

Question 37

In the three-bottle chest drainage system set up shown, the maximum suction pressure (cmH2O) generated inside the underwater seal bottle would be minus

Answer 37

Depth of tube in water in bottle 3

Question 38

Of the following, the LEAST likely to occur during one-lung ventilation in the lateral decubitus position is a. Intrapulmonary shunt b. V/Q mismatch c. Hypercarbia d. Hypoxia e. Hypoxic pulmonary vasoconstriction

Answer 38

c. Hypercarbia Single-lung ventilation leads to a **right-to-left intrapulmonary shunt** as the nondependent lung continues to undergo perfusion with no ventilation, leading to a widened alveolar-to-arterial (A-a) oxygen gradient, which may contribute further to **hypoxemia**. Factors leading to decreased blood flow to the ventilated lung also lead to hypoxemia. Such factors include: Low Fio2 leads to **hypoxic pulmonary vasoconstriction** in the dependent ventilated lung High mean airway pressures in the dependent ventilated lung Vasoconstrictor agents Intrinsic PEEP The lateral decubitus position under anesthesia: Under anesthesia, there is a decrease in functional residual capacity. The upper lobe moves under anesthesia to a more favorable portion of the compliance curve versus the lower lung, which lies now on a less favorable portion of the compliance curve. Neuromuscular blockade contributes to abdominal contents pressing against the dependent hemidiaphragm, thereby restricting ventilation. Open non-dependent lung leads to variation in compliance and thus **worsens ventilation-perfusion (V/Q) mismatch** - thereby leading to hypoxemia. **Carbon dioxide elimination is usually unaffected **in using single-lung ventilation with adequate maintenance of minute ventilation. Both lungs may be affected independently by single-lung ventilation. The ventilated-dependent lung is prone to ventilator-induced lung injury due to higher tidal volumes used. The nondependent nonventilated lung is prone to injury by surgical trauma and ischemia-reperfusion injuries. Considering these physiological changes in single-lung ventilation is vital to safely performing the anesthetic technique and airway management. Reference: StatPearls Single-Lung Ventilation https://www.ncbi.nlm.nih.gov/books/NBK538314/"